Provider Demographics
NPI:1396062725
Name:NGO, VAN (LAC)
Entity type:Individual
Prefix:MR
First Name:VAN
Middle Name:
Last Name:NGO
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14151 NEWPORT AVE
Mailing Address - Street 2:102
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-5163
Mailing Address - Country:US
Mailing Address - Phone:714-838-8931
Mailing Address - Fax:714-838-1114
Practice Address - Street 1:14151 NEWPORT AVE
Practice Address - Street 2:102
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-5163
Practice Address - Country:US
Practice Address - Phone:714-838-8931
Practice Address - Fax:714-838-1114
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-25
Last Update Date:2010-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12696171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist